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Tooth Erosion 

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CAUSES & PREVENTION

Paul Rowlands has had his project on potential damage to permanent teeth from acidic drinks published in the Dentist magazine. It is good that his excellent work with Cockermouth School has been acknowledged nationally.

What is Tooth Erosion?

Enamel, the outer layer of the tooth is made of mineral. When acid contacts the tooth, the enamel is dissolved away, a process called tooth erosion.

Is it different from tooth decay?

Tooth decay occurs when sugar is converted into acid by bacteria. Tooth erosion is caused by acid directly from the diet.

Why is it important?

Teeth wear throughout life because of normal functions such as eating. An increase in the rate of tooth wear can cause problems later in life.

What are the signs of tooth erosion?

  • Sensitivity to hot and cold
  • Reduction in the length of teeth
  • Cupped biting surfaces of the back teeth
  • Fillings projecting above the tooth surface
  • Teeth looking yellow

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Are some people more likely to get tooth erosion?

  • Overweight people can have acid coming up from the stomach into the mouth
  • People who vomit frequently for example - bulimia nervosa
  • Some medications cause a dry mouth so the teeth are more at danger from acid
  • People with asthma tend to breathe through the mouth which dries the teeth
  • Diabetics have increased thirst. They must avoid frequent acid drinks.

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Which foods cause tooth erosion?

 Any food or drink which is acidic will cause tooth erosion.

These include:

  • Citrus fruits - oranges, lemons, grapefruits
  • Vinegar and pickles
  • Yogurt
  • Fruit juices
  • Carbonated drinks - including low calorie and sports drinks
  • Vitamin C tablets

 Which drinks are good?

Drinks which are not acidic include:

  • Milk
  • Tea and coffee
  • Water
  • Sugar-free cordial eg Ribena Toothkind

 How can you prevent tooth erosion?

  • Reduce the number of acid drinks to a minimum
  • Don't brush your teeth immediately after eating. Acid dissolves the outer layer of enamel. This layer can reattach over the next two hours if it isn't brushed away
  • Chew sugar-free gum for 5 minutes after every meal to neutralise acid
  • Try to avoid too many acidic foods such as citrus fruits, tomato ketchup and vinegar
  • After exercise, saliva flow is reduced. Acid has a better chance of attacking teeth so avoid acidic drinks after exercise

Take a look at our Top Tips below for details on how to prevent Tooth Erosion.

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TOP TIPS TO AVOID TOOTH EROSION

1. Reduce frequency of acid intake

2. Don't brush your teeth immediately after a meal

3. Chew sugar-free gum for 5 minutes after a meal

4. After sport, drink a fluid with neutral pH such as water or milk

5. Remember it is as important to avoid tooth erosion as tooth decay and gum disease

6. Visit the dentist regularly to have your teeth checked for signs of tooth erosion  

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Project structure
Cockermouth School, a state comprehensive secondary school was undertaking a campaign to promote healthy living for its pupils. I arranged a meeting with Mrs Gail Harris, the deputy head teacher and discussed the possibility of using the school’s pupils as the target for my project. We discussed the background to tooth erosion and how, if educated at a young age, possible future dental problems could be prevented. The school hadn’t covered oral health within their campaign so I saw my project as a good opportunity to help the local community.

St. Helen’s Dental Practice has a series of advice sheets for children and parents but there is not much detail on tooth erosion.

In view of this, I decided to produce a questionnaire about tooth erosion and the frequency of intake of acidic drinks. The sample population for the questionnaire was the pupils from Year 7 to 11 (age 11 to 15) at Cockermouth School. The second stage of the project was to produce an advice sheet based on my findings in the questionnaire for distribution at Cockermouth School and to children at the practice.

At time of writing, the advice sheets are not back from the printers so the final stage is not yet completed. I plan to distribute the advice sheet to the year with the poorest results from the questionnaire. I will then re-distribute the questionnaire to audit the success of the advice sheet.

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Literature review
A recent 2-part paper published in the BDJ looked at dental erosion in a group of 14-year old school children.

The first part looked at prevalence of tooth erosion and the influence of socio-economic backgrounds. The study compared level of tooth wear with socio-economic status. Results showed that 48% had low erosion, 51% had moderate and 1% had severe erosion. There was significantly more erosion in males than females and more erosion in teenagers from the lowest socio-economic categories. The paper concluded that moderate levels of tooth erosion were common in 14-year old children which may lead to clinical problems and aetiological factors need to be investigated further.

The second part looked at the influence of dietary intake. The results showed that over 80% of children regularly consumed soft drinks, but half of these had a relatively low weekly consumption. 10% of those questioned consumed 22 or more intakes of carbonated drinks per week. The conclusion was that soft drink consumption was high and that there is a relationship between dental erosion and dietary intake.

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The questionnaire
The first part of the questionnaire was designed to find out how much the target population know about the causes and effects of tooth erosion. There are questions about the causes, effects and precipitating factors. The second part of the questionnaire asks the individual about their acidic drink intake.I also asked the age and gender of the participant.

Once I had written the questionnaire, I wanted to get some advice on the content and language used. Firstly, I contacted Diana Scarrott at the BDA. She suggested that I should have a brief description of what tooth erosion is, to get the children thinking on the right lines. She made the suggestion of putting some silly answers to see if the person answering was reading the question or just ticking random boxes. She proposed that when investigating drink consumption, we should ask for times per day rather that times per week.

Not having had very much contact with 11-15 year olds, I needed to get some advice on the language I had used to make sure that it wasn’t too ‘clinical’ and could be understood by the target population. Gail Harris gave me some helpful tips on phrasing the questions so they would be easy to understand.

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Materials and Method
The questionnaire was completed anonymously by years 7 to 10 at Cockermouth High School. They were completed during the morning registration session. The results were divided into two main sections; knowledge (results of the true/false section) and habits (results of the drink consumption section).

I collected the questionnaires 1 week after distributing them. Firstly, I separated them into year and gender groups. They were marked by hand. The marks for questions 1-3 were grouped together as they all looked at the background to tooth erosion. The marks for question 4 (Foods causing tooth erosion) and question 5 (Drinks causing tooth erosion) were counted separately. To calculate the acid drink intake, I added the values given for fruit juice, soft drink, isotonic sports drink and any ‘others’ which had erosive potential. The data was compiled using a spreadsheet.

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Results
I distributed 600 questionnaires and received back 519 completed papers, giving a very good (87%) response. Table 1 shows the profile of the study group.

Table 1 Distribution of sample by age and gender
Tooth Erosion - Table 1

Figure 1 shows the average scores achieved by each of the year groups and figure 2 shows the male and female comparison. The average for the whole population was 59.79% with a highest score of 61.89% by year 10 and a lowest score of 55.77% by year 7. The score for years 8-10 was significantly higher than that for year 7 (Z=4.47) with a confidence level of 0.5%. Females (60.7%) scored slightly higher than males (59.1%), a significant difference (Z=1.79) with a confidence level of 5%.
Fig 1

The breakdown into sections reveals a poor score (38.84%) on the questions about foods that cause erosion. There was a high number of individuals (70%) who think chocolate is a cause of tooth erosion.

One of the most interesting findings was the poor response to question 2a. which asks if tooth surface loss is increased if you brush your teeth after a meal. Most (87%) don’t realise that it is harmful to brush immediately after eating a meal. There was an article in the Mirror newspaper that told how acidic and abrasive foods such as citrus fruits and raw vegetables which are considered to be health foods actually cause more harm to teeth than junk food such as beef burgers and chips.

The results for question 5 (drinks that cause erosion) were reassuringly high (69.04%) although there remains scope for improvement.

Figure two compares the knowledge of male and female, and there was no significant difference.
Fig 2

Figures 3&4 present the values for daily acid drink intake. Males average 3.51 and females average 3.12 acidic drinks per day This is significantly different (Z=2.04) with confidence interval of 2.5%. Year 9 had the lowest intake (2.89) while the highest consumption was by year 7 (3.88). These values are significant (Z=3.49) with a confidence interval of 0.5%. The workings for the significance values can be found in the appendix.
fig 3

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Design of the advice leaflet
The leaflet was to be aimed primarily at children so it had to be written at a level that they could understand. I felt that it was important to keep the text brief, so as not to overload the reader with too much information. While creating the draft copy, I aimed to keep it in the style of the other practice leaflets. The layout is a double-folded A4 sheet, giving 6 sides measuring approximately 21x10cm.

The front page is designed to catch the attention of the reader and summarises the theme of the leaflet. The back page summaries the main points in a ‘Top Tips’ section. On the second page, I started by explaining that tooth erosion occurs when acid touches enamel, the outer layer of the tooth. I thought that some children may be unsure of the difference between decay and erosion so I described how tooth erosion is caused by acid directly from the diet, while decay is caused by acid produced by bacteria. Just over 1/3 of the questionnaire participants (35%) didn’t think that tooth erosion was as important as tooth decay so I included a section explaining that tooth erosion speeds up the natural tooth wear process, leading to problems later in life.

The next section lists the signs of tooth erosion. This is intended to show the reader that a dentist will be able to detect tooth erosion, therefore the importance on attending for regular check-ups.

While soft drinks and fruit juice are the main causes of tooth erosion, there are other precipitating factors. There has been a lot of publicity recently on obesity, particularly in children, which in addition to problems such as heart disease, has an association with tooth erosion. I wanted to stress the increased risk of tooth erosion in people with medical conditions such as diabetes and asthma, one of the most common childhood illness.

The final section shows how tooth erosion can be prevented. In response to the results from the questionnaire, I have explained how brushing teeth after a meal can lead to tooth surface loss, whereas chewing sugar-free gum for 5 minutes can reduce tooth surface loss. My final point gives advice on drinks after exercise. Isotonic drinks are heavily advertised and endorsed by sports stars, so children would expect them to be ideal refreshment after exercise, so to counter this, I promoted the consumption of drinks such as milk or water.

The sketch copy of the leaflet which I produced was sent to Visual Link in Carlisle and it was transferred onto computer. A draft copy was produced, allowing minor modifications to be made, before it was sent to Thurnams printers for the final print

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Phase 1 conclusions

  • Before I started the project, I was aware that there was a problem with intake of acidic drinks by schoolchildren. The results support this, with an average of more than 3 acid drinks consumed per day, the highest consumption by year 7 and males within the sample population.
  • With reference to the knowledge section of the questionnaire, year 10 gained the highest scores with an average score of about 60% across the population. In hindsight, I should have included a “don’t know” column to reduce the number of guesses made by the children.
  • After discussing the results and implications of the with Gail Harris, Cockermouth School is considering replacing the soft drink vending machines with healthier options, such as bottled water or Ribena Toothkind. This was the most pleasing aspect of the project because it showed me that as a profession, we can guide people towards healthier lifestyles.

Phase 2
The second phase of the project will look to audit the advice sheet with the following timescale:

  1. Early June - Distribute the advice leaflet to Year 7 pupils.
  2. 2 weeks later- Repeat the questionnaire to Year7.
  3. By the end of June I will have the results of the audit collated and analysed.

Bibliography

  1. Y.H. Al-Dlaigan, et al. Dental erosion in a group of British 14-year-old, school children. BDJ, Vol 190 no.3, Feb 10 2001 & BDJ, Vol 190 no.5 March 10 2001.
  2. Report by Simone Cave. Are you brushing your teeth away? The Mirror, Thursday Jan 18 2001.
  3. R. Welbury. Paediatric Dentistry.

 Acknowledgements

  1. Meredyth Bell for her support and encouragement.
  2. Richard Bell for helping with the design and printing of the questionnaire and advice leaflet.
  3. Cockermouth School for allowing me to use the pupils as my study population and help with the statistical analysis.
  4. Gail Harris, Deputy Headteacher of Cockermouth School for her help designing the questionnaire and co-ordinating the project.
  5. Diana Scarrott of the BDA for help with the questionnaire.

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